Chapter 12 My Nursing Test Banks

The nurse caring for a 46-year-old male who has been drinking heavily for 3 years is aware of the potential for alcohol withdrawal syndrome based on the knowledge that physiologically:

1. Alcohol is a stimulant that increases gamma-aminobutyric acid (GABA).

2. The neurotransmitters inhibit impulses on the neurons.

3. The CNS has become accustomed to the depressant effects of the alcohol and CNS excitability develops when alcohol is no longer present.

4. The neuroreceptors in the brain can begin to initiate a chemical reaction of normalcy.

Correct Answer: 3

Rationale 1: Alcohol suppresses the production of GABA. When alcohol is withdrawn, GABA may resume normal function which is to inhibit transmission of impulses.

Rationale 2: Neurotransmitters are usually balanced between inhibitory and stimulatory. In the presence of alcohol, transmitters are inhibited. With the absence of alcohol, the transmitters become stimulated.

Rationale 3: When exposed to repeated doses of alcohol, the central nervous system (CNS) becomes accustomed to the depressant effects of the alcohol and produces adaptive changes in an attempt to function normally. In the absence of or with a significant decrease in the amount of alcohol, chaos erupts within the CNS. When alcohol is no longer acting as a depressant, the compensatory actions cause excessive CNS excitability.

Rationale 4: With the withdrawal of alcohol, neuroreceptors do not regain normalcy. Instead they are prone to become overstimulated due to the depressant effect of alcohol.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-1: Explain the relationship between the pharmacologic effects of alcohol and the cause of withdrawal symptoms.

Question 2

Type: MCSA

Which finding suggests to the nurse that a patient is experiencing early physiologic clinical manifestations of alcohol withdrawal? The patient:

1. Is yelling at the nurse and demanding to go home

2. Has a BP of 160/90, HR of 110, and T of 100

3. Is a well-known repeat offender and is demanding a drink

4. Cannot sit up straight or respond appropriately to questions

Correct Answer: 2

Rationale 1: Yelling and acting belligerent is a behavioral and neuropsychiatric manifestation of alcohol withdrawal syndrome.

Rationale 2: Vital signs including temperature and pulse oximetry are evaluated. Early indications of alcohol withdrawal tend to be milder increases in heart rate, temperature, and blood pressure with more severe symptoms such as hallucinations developing as the patient progresses through the continuum.

Rationale 3: Being a repeat offender and demanding a drink is a behavioral manifestation of alcohol withdrawal syndrome.

Rationale 4: Lethargy and decreased responsiveness is a later manifestation of alcohol withdrawal syndrome.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-1: Explain the relationship between the pharmacologic effects of alcohol and the cause of withdrawal symptoms.

Question 3

Type: MCSA

A patient with a history of alcohol misuse has been admitted for treatment. The essential components of the nursing assessment include:

1. The use of addiction standards to assess for drinking patterns

2. The inclusion of objective and subjective input from the patient including signs of anxiety and patterns of usage

3. The amount of denial that the patient is exhibiting

4. The amount of time spent obtaining, using, and recovering from alcohol

Correct Answer: 2

Rationale 1: The actual standard for the interview is the CIWA-Ar which is a standardized interview tool that is used for assessment.

Rationale 2: It is important to consider a patients nonverbal responses, anxiety, and presence or absence of eye contact for clues. The nurse questions the patient and/or family related to current and past alcohol use and family history of alcohol problems.

Rationale 3: Patients typically either deny alcohol use or admit to consumption of a significantly lower amount of alcohol.

Rationale 4: This is not a part of the nursing assessment for alcohol use.

When the CAGE questionnaire is used to guide the assessment of alcohol misuse, the nurse would ask which questions?

1. Have you ever crashed overnight in an unfamiliar area, arrived late for work, given up family and friends, or escaped arrest by the law?

2. Have you ever felt the need to cut down on drinking, felt annoyed by criticism of your drinking, ever had guilty feelings about your drinking, or ever had an eye opener first thing in the morning to get rid of a hangover?

3. Have you ever had a big crisis that led to arrest and grief from your family and friends and tried to explain away your actions?

4. Have you called off or were absent from work because you had too much to drink and needed to sleep it off?

Correct Answer: 2

Rationale 1: This is an example of behavior that is considered maladaptive. This type of behavior could be related to dependency but is not necessarily indicative of dependency.

Rationale 2: The acronym helps the clinician to recall these four questions. Have you ever felt the need to CUT down on drinking? Have you ever felt ANNOYED by criticism of your drinking? Have you ever had GUILTY feelings about your drinking? Have you ever had an EYE opener first thing in the morning to steady your nerves or get rid of a hangover?

Rationale 3: This is an example of a situational crisis and not necessarily of dependency.

Rationale 4: This is not an appropriate question to ask when utilizing the CAGE questionnaire.

A patient who misuses alcohol finished drinking at noon. At 6 p.m. which autonomic manifestations of alcohol withdrawal would the nurse assess in the patient?

1. Nausea and abdominal cramps

2. Diaphoresis and tremors

3. Anorexia and diarrhea

4. Auditory-visual hallucinations and global confusion

Correct Answer: 2

Rationale 1: These are not autonomic manifestations of alcohol withdrawal.

Rationale 2: Because alcohol is short acting, the nurse anticipates that signs and symptoms of minor withdrawal commonly appear within 6 to 12 hours of the last ingestion. Autonomic manifestations that occur during the first hours of alcohol withdrawal include hyperventilation, tachycardia, palpitations, hypertension, increased body temperature, hyperreflexia, insomnia, restlessness, diaphoresis, tremors, mydriasis, and seizures.

Rationale 3: Anorexia and diarrhea are nonspecific gastrointestinal symptoms that not associated with either drug or alcohol abuse.

Rationale 4: This is not appropriate in the Critical Care environment because the nurse/ patient ratio in this environment is usually 12 patients per nurse. This ratio allows for close assessment and monitoring of the patient experiencing alcohol withdrawal syndrome.

Rationale 5: The goals of management for alcohol withdrawal include preventing, recognizing, and treating symptoms while providing a safe environment for the patient.

The nurse is planning to use the Clinical Institute Withdrawal Assessment (CIWA-Ar) scale with a patient who has been recently admitted with pancreatitis. When using this measurement tool, the nurse must realize that:

1. The lower the score, the greater the patients risk for severe withdrawal symptoms.

2. The higher the score, the lower the patients risk for severe withdrawal symptoms.

3. Pharmacologic therapy is matched with the score to direct the level of care required.

4. Sixteen specific areas are scored and assessed with this tool.

Correct Answer: 3

Rationale 1: The higher the score, the greater the patients risk for severe withdrawal symptoms.

Rationale 2: The higher the score, the greater the patients risk for severe withdrawal symptoms.

Rationale 2: Response to treatment is an evaluation of therapy given. Treatment with further medication would be based on that evaluation and the patients level of consciousness. Medication should not be automatically administered without further assessment.

Rationale 3: Patients are medicated with benzodiazepines when they cross a designated threshold of severity. Frequency of assessments will be determined by the severity, treatment, response to treatment, and overall acuity.

Rationale 4: Physiologic and behavioral symptoms determine intervention as opposed to the amount of observation time required to monitor the patient.

The nurse suspects that a patient is dependent on alcohol rather than abusing alcohol when what is assessed?

1. Alcohol is taken in larger amounts than planned and there is proof of tolerance.

2. Recurrent legal problems related to substance abuse are present.

3. Despite social and interpersonal problems, the person continues to use alcohol.

4. The person uses alcohol in physically hazardous situations.

Correct Answer: 1

Rationale 1: This defines dependence. Alcohol dependency (also known alcoholism) is a pattern of maladaptive behavior associated with one or more of the following: withdrawal symptoms; proof of tolerance; relentless desire to cut down or control use; occupational, social, and recreational tasks are given up; alcohol taken in a larger amounts than planned; time is spent obtaining, using, and recovering from the alcohol; and alcohol use continues regardless of physical and psychological troubles.

Rationale 2: Recurrent legal problems are associated with alcohol abuse and not dependency.

Rationale 3: Social and interpersonal problems are associated with alcohol abuse and not dependency.

Rationale 4: Using alcohol in physically hazardous situations is associated with alcohol abuse and not dependency.

A patient with a myocardial infarction is withdrawing from alcohol. The patient is nauseated and having tremors despite receiving medications for withdrawal. The nurse suspects the patient is experiencing which electrolyte imbalance?

An adolescent patient is admitted after ingesting 20 500 mg acetaminophen (Tylenol) tablets as a suicide attempt. The patient is currently nauseated, vomiting, and diaphoretic with a BP of 96/52. What will be the priority in this patients care?

1. Have a serum acetaminophen level drawn.

2. Observe for possible urticaria and bronchospasms.

3. Provide the first oral dose of acetylcysteine (Mucomyst) in orange juice.

4. Start an intravenous access line for rehydration.

Correct Answer: 1

Rationale 1: The predicted risk of toxicity from a single acute overdose relies on the time of ingestion and serum acetaminophen level. Whether a level is toxic or nontoxic can only be interpreted when the time of ingestion is accurately accounted for. The Rumack-Matthew nomogram can be used to predict hepatic toxicity between 4 and 24 hours after an acute ingestion.

Rationale 2: These symptoms are side effects of intravenous administration of acetylcysteine NAC (Mucomyst).

Rationale 3: This medication is administered after the initial acetaminophen level is drawn. It must be administered within 424 hours after acetaminophen.

A patient who ingests several alcoholic beverages each day has been taking 1 gm of acetaminophen (Tylenol) six times a day and Percocet for pain relief following knee surgery. The patient is currently complaining of nausea with right upper quadrant pain and has an AST of 60 units/L and ALT of 45 units/L. Which additional laboratory studies would the nurse use when assessing this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Prothrombin time and INR to identify coagulation abnormalities

2. Serum potassium to evaluate kidney function

3. Serum acetaminophen level plotted on a Rumack-Matthew nomogram

4. Toxicology screen to identify other substances ingested

5. Urine screen for myoglobin to detect tissue damage

Correct Answer: 1,3,4

Rationale 1: The PT/PTT and INR are the most important levels to obtain because elevation of these levels is indicative of liver dysfunction and puts the patient at risk for bleeding.

Rationale 2: A more accurate assessment of renal function would be creatinine and blood urea nitrogen in addition to potassium.

Rationale 3: The amount of acetaminophen this patient consumes is 6000 mg/day. This exceeds the safe level of 4000 mg/day. The patient needs to be assessed for acetaminophen toxicity.

Rationale 4: An ethanol level and opiate level would also be appropriate for this patient, given the patients history.

Rationale 5: Urine myoglobin is only used for those patients with tissue trauma such as those with severe orthopedic injury and burns.

What complications might a patient develop in response to portal hypertension?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Hepatomegaly

2. Splenomegaly

3. Ascites and variceal hemorrhage

4. Atherosclerotic plaques

5. Portal system pressure 5 to 10 mm Hg

Correct Answer: 1,2,3

Rationale 1: In the early stages of portal hypertension, blood collects in the sinusoids of the liver to compensate for the elevated pressure. As the pressure remains elevated, the liver enlarges.

Rationale 2: The spleen is a part of the portal system and as pressure increases, blood will back up in the system and also collect in the spleen.

Rationale 3: Ascites is a marker for severe progression of liver disease. The high pressure frequently causes the esophageal and/or gastric varices to rupture and bleed. The most common site for a variceal bleed is the submucosa of the distal end of the esophagus.

Rationale 5: This is a normal range of portal pressure. Portal hypertension is defined as portal pressure 20 mm Hg.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-8: Explain the relationship between portal hypertension and the development of decompensated liver disease.

Question 15

Type: MCSA

The nurse is preparing to administer the third dose of aldactone (Spironolactone) to a patient with cirrhosis and ascites. What would cause the nurse to question the administration of this medication?

1. Serum creatinine of 1.6 mg/dL

2. Serum sodium of 130 mEq/L

3. Serum potassium of 5.7 mEq/L

4. Weight gain of 0.2 kg

Correct Answer: 3

Rationale 1: The serum creatinine of 1.6 mmol/L is within normal limits.

Rationale 2: The serum sodium of 130 mEq/l, even though it is low, does not meet the criteria to hold the medication.

Rationale 3: The nurse anticipates this potassium-sparing diuretic may be discontinued if the potassium level is greater than 5.3 mEq/L. This medication needs to be held or discontinued as this patients potassium level is 5.7 mEq/L.

Rationale 4: A weight gain of 0.2 kg is not an indication to hold diuretics. The objective of diuretics is to reduce the ascites and peripheral edema.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12-8: Explain the relationship between portal hypertension and the development of decompensated liver disease.

Question 16

Type: MCSA

A patient with ascites is recovering from a paracentesis where 8 liters of fluid have been removed. What will the nurse monitor in order to detect a common complication after this procedure?

1. Blood pressure at least every half hour until the patient is stable

What will the nurse use to accurately assess the fluid status of a patient with ascites?

1. Abdominal percussion

2. Daily weights

3. Measurement of abdominal girth

4. Presence of peripheral edema

Correct Answer: 2

Rationale 1: Abdominal percussion may be difficult and inaccurate in obese patients.

Rationale 2: Daily weights are accurate and objective indicators of fluid gain and loss and are directly related to sodium balance. A weight gain of 1 kg is equivalent to the retention of 1 liter of fluid.

Rationale 3: The measurement of abdominal girth is subjective and often inaccurate.

Rationale 4: The presence of peripheral edema is subjective and often inaccurate.

A patient with portal hypertension and hepatic encephalopathy asks why meat is being restricted in the diet. The nurse explains that a reduced protein diet will:

1. Help to restore his liver function

2. Help decrease the amount of ammonia in his blood

3. Give the liver a chance to rest

4. Prevent fluid from leaking into the abdomen

Correct Answer: 2

Rationale 1: Dietary restriction does not restore liver function but instead lower the production of ammonia.

Rationale 2: The goal of treatment is to reduce ammonia production and/or increasing its removal and lower elevated ammonia levels. This may occur by a variety of methods. One method is limiting the amount of protein in the diet.

Rationale 3: Restricting protein in the diet does not rest the liver.

Rationale 4: Ascites can be controlled with sodium and fluid restriction, the use of diuretics, and intermittent administration of salt-poor albumin.

Rationale 2: Accidental migration of the tube can result in airway obstruction. This requires immediate intervention by cutting all the lumens of the tube to rapidly deflate them and removing the tube. Maintenance of the airway is the priority.

Rationale 3: Although this is important to keep the patient from pulling out the tube, airway takes priority.

Rationale 4: Although it is important to maintain this pressure against the varices to prevent bleeding, maintaining the airway is the priority.

A patient is recovering from an endoscopy with banding of esophageal varices. Which intervention would have the highest priority immediately following the procedure and until the patient is fully awake?

1. Determining if the patient is able to swallow

2. Irrigating the NG tube with saline to detect any additional bleeding

3. Maintaining the patient in the left lateral decubitus position

4. Monitoring the patients vital signs every hour

Correct Answer: 3

Rationale 1: During endoscopy, patients may have a topical anesthetic sprayed to the throat area, which may impair swallowing. The nurse waits until the patient is awake to assess swallowing.

Rationale 2: Irrigation is done as needed to maintain patency.

Rationale 3: If the patient is not intubated, the nurse should position the patient in the left lateral decubitus position to protect the airway until the patient is fully awake. Airway protection is always top priority.

Rationale 4: The nurse monitors vital signs, including temperature and oxygen saturation and level of pain and consciousness, until the patient returns to baseline (typically every 10 to 15 minutes for 30 minutes to an hour, then per ICU protocol, or more frequently depending on acuity).

A patient with esophageal varices received octreotide (Sandostatin) 100 microgram intravenous bolus and the nurse is preparing to start a continuous infusion of the medication. The drug is diluted 500 micrograms in 250 mL of 0.9% normal saline to be administered at 50 mcg/hour. How many milliliters per hour should the intravenous infusion pump be set to deliver the correct dose?

1. 100 mL

2. 50 mL

3. 12.5 mL

4. 25 mL

Correct Answer: 4

Rationale 1: The rate of 25 L/hr may be correctly calculated by using the formula: Dose divided by concentration equals rate. The dose is 50 mcg/hour divided by the concentration (500 mcg/ 250 mL). This is 50 divided by 2 = 25 mL/hour.

Rationale 2: The rate of 25 L/hr may be correctly calculated by using the formula: Dose divided by concentration equals rate. The dose is 50 mcg/hour divided by the concentration (500 mcg/ 250 mL). This is 50 divided by 2 = 25 mL/hour.

Rationale 3: The rate of 25 L/hr may be correctly calculated by using the formula: Dose divided by concentration equals rate. The dose is 50 mcg/hour divided by the concentration (500 mcg/ 250 mL). This is 50 divided by 2 = 25 mL/hour.

Rationale 4: The rate of 25 L/hr may be correctly calculated by using the formula: Dose divided by concentration equals rate. The dose is 50 mcg/hour divided by the concentration (500 mcg/ 250 mL). This is 50 divided by 2 = 25 mL/hour.

A patient with bleeding esophageal varices is scheduled to receive a bolus followed by a continuous infusion of octreotide (Sandostatin). The nurse preparing the medication would:

1. Anticipate that the medication will stop the bleeding immediately.

2. Notify the physician if the patient has cardiac disease because the medication is contraindicated.

3. Recognize that doses of 100 mcg/hour and higher are associated with better outcomes.

4. Review serial hematocrit levels to determine if the patient is continuing to bleed.

Correct Answer: 4

Rationale 1: This medication is effective in temporarily stopping the bleeding in approximately 80% of patients.

Rationale 2: Octreotide (Sandostatin) has an excellent safety margin and is safe for patients with cardiac disease.

Rationale 3: Doses greater than 50 mcg/hr may increase systemic venous pressure and do not increase the portal hypotensive effects.

Rationale 4: To evaluate response to the octreotide (Sandostatin) infusion, the nurse would continue to monitor the patients hemodynamic status and expect to see the patients vital signs return to normal, urine output increase, and a decrease in overt bleeding: hematemesis, melena, and hematochezia. Serial hematocrit levels should be evaluated.

The nurse is planning care for a patient with alcohol withdrawal syndrome. Which criteria will the nurse use to determine the severity of the patients symptoms from this syndrome?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Current blood alcohol level

2. Concurrent illnesses

3. History of previous withdrawals

4. History of substance abuse

5. Current vital signs

Correct Answer: 1,2,3,4

Rationale 1: Severity is believed to be dose dependent with more severe withdrawal associated with higher blood alcohol concentrations.

Rationale 2: Severe withdrawal is intensified by the stress of concurrent illnesses.

Rationale 3: Having a history of previous withdrawals suggests that additional withdrawals can be progressively more severe. This is the kindling effect.

Rationale 4: The use of other addictive drugs impacts the severity of withdrawal.

Rationale 5: Current vital signs will not impact the severity of alcohol withdrawal.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-1: Explain the relationship between the pharmacologic effects of alcohol and the cause of withdrawal symptoms.

Question 26

Type: FIB

During a focused assessment the nurse learns that a patient consumes one 1000 mL box of wine each day. If the patient is using a 5 ounce glass, how many drinks would the nurse document that this patient consumes daily?

Standard Text: Round your number to the nearest whole number.

Correct Answer: 7

Rationale : One ounce is equivalent to 30 mL. Multiply 30 mL x 5 = 150 mL as the amount of each glass of wine. Next divide 150 mL by 1000 mL or 1000 mL/150 mL = 6.67, which is the number of drinks the patient consumes each day. With rounding to the nearest whole number, the nurse would document that the patient consumes 7 drinks per day.

A patient with a history of taking acetaminophen (Tylenol) for osteoarthritis pain is surprised to learn the diagnosis of liver failure. What will the nurse explain to the patient about this diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Liver damage can occur when the maximum daily dose of acetaminophen is taken repeatedly.

A patient comes into the emergency department after ingesting 50 650 mg tablets of arthritis-strength acetaminophen (Tylenol) 2 hours ago. What interventions will the nurse prepare to implement at this time?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Provide medication to induce vomiting.

2. Prepare to insert a nasogastric tube for gastric lavage.

3. Contact the pharmacy for activated charcoal.

4. Draw a serum acetaminophen level.

5. Administer N-acetylcysteine (NAC) (Mucomyst).

Correct Answer: 1,2,3

Rationale 1: If the time of ingestion was less than 4 hours, induction of emesis may be considered.

Rationale 2: If the time of ingestion was less than 4 hours gastric lavage of pill fragments may be considered for treatment.

Rationale 3: If the time of ingestion was less than 4 hours, administration of activated charcoal to reduce absorption may be considered.

Rationale 4: If the time of ingestion is greater than 4 hours but less than 24, a serum acetaminophen level should be immediately drawn.

Rationale 5: This medication is used if the patient is at risk for hepatotoxicity.